title: The process of practice redesign in delirium care for hospitalised older people: a participatory action research study.
abstract: BACKGROUND
  In 2007 three researchers completed a 6-month study in one 32-bed acute care medical ward in a large hospital in New South Wales, Australia. The problem drawn to the attention of researchers was that approximately 60% of older people were delirious on arrival or develop incident delirium during their hospital stay. Lack of recognition, underreporting and inadequate care responses to delirium in hospitalised older people signalled a major practice problem.
  
  
  OBJECTIVE
  To collaboratively explore ways in which clinical practice could be improved.
  
  
  METHODS
  We selected Participatory Action Research (PAR) as the methodology to involve health practitioners in practice redesign. PAR is a process in which 'we', researchers and participants, systematically work together in cycles of 'looking, thinking and acting'. Delirium and the high percentage of older people who succumb to this condition was the main practice problem requiring a response. Eight volunteer clinicians and three researchers met weekly as a group for 13 sessions over 6 months. Clinicians set the agenda for redesign of practice. Raising awareness about delirium and its prevention were the selected action strategies. A delirium alert protocol was developed for implementation by the clinicians and later evaluation as a separate study.
  
  
  RESULTS
  There was evidence that practice had changed. Physical and chemical restraints had not been used for 3 months subsequent to the study's completion. The nurse manager reported that early detection strategies had prevented episodes of acute hyperactive delirium. Whilst there continued to be older people admitted with a diagnosis of delirium, there were fewer incidences of delirium developing on the ward and there was less disruption to other patients, especially at night. The strategy of raising the awareness of delirium in older people was successful. We are confident that working collaboratively with practitioners is the way to bring evidence to practice in delirium care for older people in acute care settings.
authors.affiliation: School of Nursing and Midwifery, Faculty of Health, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
authors.forename: Jenny
authors.initials: J
authors.lastname: Day
authors.forename: Isabel
authors.initials: I
authors.lastname: Higgins
authors.forename: Tina
authors.initials: T
authors.lastname: Koch
mesh_terms: D000368:Aged; D001291:Attitude of Health Personnel; D003693:Delirium / Q000175:diagnosis / Q000209:etiology / Q000451:nursing*; D042241:Early Diagnosis; D055318:Evidence-Based Nursing; D017144:Focus Groups; D015577:Geriatric Assessment; D005851:Geriatric Nursing / Q000193:education / Q000458:organization & administration*; D006302:Health Services Research; D006757:Hospital Units / Q000458:organization & administration*; D006801:Humans; D033262:Narration; D020380:Needs Assessment; D009517:New South Wales; D009730:Nursing Assessment; D015404:Nursing Methodology Research; D009741:Nursing Staff, Hospital / Q000193:education / Q000458:organization & administration / Q000523:psychology; D009936:Organizational Innovation; D017410:Practice Guidelines as Topic; D012107:Research Design; D012149:Restraint, Physical; D012307:Risk Factors; D013850:Thinking; D017749:Total Quality Management / Q000458:organization & administration*